intake NEW Triple Beneficiary Name * Beneficiary ID Number * Beneficiary's Age * Less than 5 years From 5 to 12 years From 12 to 18 years Over 18 years Parent's Triple Name * Contact Number * Email Has he/she been diagnosed with autism spectrum disorder or a developmental disorder? * Yes No Upload a diagnostic report upload file from here choose file Maximum file size: 5MB Has the hearing test been performed? * Yes No Upload a hearing test report upload file from here choose file Maximum file size: 67.11MB Desired Rehabilitation Services: (More than one service can be selected) * Free Consultation Feeding problems and food selectivity Comprehensive Development Assessment Home Services Intensive Rehabilitation Program Vocational Rehabilitation One package (24 sessions in speech-language therapy or occupational therapy) Remote Family Training For severe behavioral problems and functional communication (24 sessions) School Induction Program Payment Method * Cash Insurance (Tawuniya) Insurance (Bupa) Insurance (Malath) Insurance (MidGulf) Has the beneficiary been registered with Autism Center of Excellence previously? * Yes No How did you learn about the Autism Center of Excellence and its services? * Through social networkingThrough a friendThrough a previous beneficiary of the center’s servicesThrough one of the center’s employeesOther How did you learn about the Autism Center of Excellence and its services? Please enter employee ID number * If you are human, leave this field blank. Send
